Failure to Update Fall Interventions and Implement Safety Measures
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision or implement appropriate interventions to prevent accidents for two residents with severe cognitive impairment and high fall risk. Both residents had multiple falls within a short period, and their care plans were not updated with new interventions following each incident, despite facility policy requiring such updates. For one resident, the care plan included the use of a fall mat when in bed, but this intervention was not consistently implemented, as the fall mat was observed under the bed rather than beside it on at least one occasion. Medical records and staff interviews confirmed that after each fall, no new interventions were added to the care plans of either resident, and the process for updating care plans post-fall was not followed. Both residents had significant cognitive deficits and mobility issues, further increasing their risk for falls. The facility's own fall policy required that a new intervention be added to the care plan after each fall, but this was not done, and required safety equipment was not always in place as specified.